LERLER encourages a collaborative multidisciplinary clinical approach with an emphasis on functional outcomes and evidence-based medicine. LER is published monthly, except for a combined

January2018features21 The effect of copper-impregnatedsocks on tinea pedis in football players

In a study of collegiate football players, at high risk of tinea pedis due to

their training environment, copper-impregnated socks were associated

with a high rate of tinea pedis symptom resolution and a low rate of new

cases—supporting claims of the socks’ antifungal potential. By Gary M. Rothenberg, DPM, CDE, CWS

29Saying ‘PTTD’ is misleading: It’s time for a new lexicon to distinguish

pathologies

Instead of using diagnostic language to describe medial column

ligamentous failure, the author proposes, practitioners should learn a new,

descriptive language to understand the nature of a patient’s pathology.

Beyond that, he proposes causality due to ligament failure.By Ian Engelman, MS, CPO

43 Promoting postsurgical weight lossand activity to address joint pain

Many who suffer chronic joint pain are unable to exercise, and as a result

of this inactivity, put on weight, which only increases joint pain. To end

this cycle, it makes sense that having surgery to relieve patients’ pain will

help them be more active and lose weight.By Keith Loria

51 Can minimalist shoes protect againstinjury by increasing foot-muscle thickness?

Improvement in abductor hallucis muscle size associated with a gradual

transition to minimalist running shoes suggests that this type of strength-

based approach can help improve foot structure and stability, which may help

runners resist development of overuse injury or relieve existing foot pain.By Nicholas A. Campitelli, DPM, FACFAS; and Scott A. Spencer, DPM

14 COVER STORYPatellofemoral painMORE ACTIVITY MEANS MORE PAIN—AND THEN LESS ACTIVITY?An increase in activity-related pain may cause patients to modify their lower-extremity functionduring tasks associated with physical activity—with deleterious effects on health and fitness.By Neal R. Glaviano, PhD, AT, ATC; Andrea Baellow, MS; and Susan Saliba, PhD, MPT, Med

IN THE MOMENTsports medicine/11Yoga reduces falls in older adultsMost volleyball-related ankle injuries occur during blockingHip strengthening optimizes PFP treatmentACL treatment in children varies widely; 90% return to sport after ACLR

plus...PUBLISHER’S MEMO / 9 Fresh opportunitiesin a New YearBy Rich Dubin

NEW PRODUCTS / 58The latest in lower extremity devices and technologies

MARKET MECHANICS /60News from lower extremity companies and organizationsBy Laura Hochnadel

21 29 51

VOLUME 10 NUMBER 1 LERMAGAZINE .COM

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Editorial Advisory BoardCraig R. Bottoni, MD | Jonathan L. Chang, MD Sarah Curran, PhD, FCPodMed | Stefania Fatone, PhD, BPOTimothy E. Hewett, PhD | Robert S. Lin, CPOJeffrey A. Ross, DPM, MD | Paul R. Scherer, DPM Erin D. Ward, DPM | Bruce E. Williams, DPM

Our Mission: Lower Extremity Review informs healthcare practitioners on current developments in the diagnosis, treatment, andprevention of lower extremity injuries. LER encourages a collaborative multidisciplinary clinical approach with anemphasis on functional outcomes and evidence-based medicine. LER is published monthly, except for a combinedNovember/December issue and an additional special issue inDecember, by Lower Extremity Review, LLC.Subscriptions may be obtained for $38 domestic and $72 international bywriting to: LER, PO Box 390418, Minneapolis, MN, 55439-0418. Copyright©2018 Lower Extremity Review, LLC. All rights reserved. The publicationmay not be reproduced in any fashion, including electronically, in part orwhole, without written consent. LER is a registered trademark of Lower Ex-tremity Review, LLC. POSTMASTER: Please send address changes to LER,PO Box 390418, Minneapolis, MN, 55439-0418.

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Warm wishes for a peace-

ful and prosperous 2018!

We are making changes to

Lower Extremity Review

that I know the LER com-

munity will find useful. Let

me take a few minutes to

explain.

First, I welcome Julia

Muino as the new LER

Editor. With more than 3

decades of experience,

Julia will be your point of

contact for day-to-day and

long-range editorial matters and will provide vision and leadership

for the editorial team. This past December, Jordana Bieze Foster

completed her long tenure as Editor; likewise, Associate Editor

P.K. Daniel has moved on to other opportunities. I thank them for

their many contributions to LER.

Second, LER Senior Editor Emily Delzell will become Editor of

LER Pediatrics. Emily is passionate about her work; we anticipate

much growth for this quarterly publication—and therefore a lot of

valuable information for your practice. The editorial effort will also

benefit from the advisory work of newly retained Consulting

Editor John Baranowski, who brings decades of medical editorial

management experience and collaboration with authors and

experts to LER.

Be assured, readers: The new LER editorial team will keep the

guiding principle of editorial integrity intact at the same time it un-

dertakes important improvements to content. For example, you’ll

soon see reference lists the end of articles in the print edition—

not just consigned to article archives at www.lermagazine.com.

We’ve realized how useful this simple change will be.

More is happening in 2018

• A missing aspect of our editorial complexion has been input

from readers. Collaboration and 2-way communication are key,

and you’ll hear more about these values as the year progresses.

The Editors and Publisher welcome your comments and con-

cerns; we want to hear suggestions for articles, and we invite you

to consider (always in discussion with the Editors) turning your

experience and expertise into a manuscript proposal. Our goal?

Open a more robust 2-way flow of information.

• The print edition of LER will undergo a graphic redesign to take

the publication to the next level of visual excellence. So will

www.lermagazine.com—in part to help you find and navigate

articles more easily and quickly.

• We will launch new editorial sections.

• The Editors will work closely with a reinvigorated editorial

advisory board and a panel of industry experts, to ensure that

content is better aligned with the needs of LER’s multi-disciplinary

audience.

• And still more to look for: The industry news section, “Market

Mechanics,” reinvented as a weekly e-newsletter; an LER virtual

trade show; on-line education; and an “On-Demand Custom

Publishing” portal, where you can combine LER content and

your own original content to create and distribute educational

materials for your patients.

• Last, we’re building a dedicated news and social media editorial

team, staffed by Karen Henry and Laura Hochnadel, formerly at

The O&P Edge.

These exciting changes will mean a richer, more integrative publi-

cation. I am grateful for the support of the entire LER community:

readers, advertisers, and industry experts, as well the LER team of

publishing professionals. Some of them have been here since the

beginning: Christine Silva (design and production), Anthony

Palmeri (web site development), New Products Editor Rikki Lee

Travolta, and Operations Coordinator Melissa Rosenthal-Dubin.

Thank you, readers and supporters of Lower Extremity Review.

As always, reach out to me any time ([email protected]).

Rich Dubin, Publisher

Publisher’s memoFresh opportunitiesin a New Year

in the moment: sports medicine

Most volleyball-related ankle injuries occur during BLOCKINGNew evidence suggests that most volleyball-related ankle injuriesare the result of a rapid inversion during blocking—often due to land-ing on an opponent or a teammate while attacking—rather than theinjury occurring during plantar flexion, as once thought, according toa study published in the January 2018 issue of the British Journal ofSports Medicine.

Five researchers viewed and analyzed videos of 24 ankle injuriesfrom major Fédération Internationale de Volleyball (FIVB) tournaments.The cohort included 14 men and 10 women. Fifteen of the injuries oc-curred during blocking, 11 of which resulted from landing on an oppo -nent and four from landing on a teammate. Of the six injuries that oc-curred during attacking, four were due to the back-row player landingon a front-row teammate and two to landing on an opponent. More-over, the study states, “When landing on an opponent under the net,the attacker landed into the opponent’s court in 11 of 12 situations butwithout violating the center line rule.” Source:Skazalski C, Kruczynski J, Bahr MA, et al. Landing-related ankle injuries do not occurin plantarflexion as once thought: a systematic video analysis of ankle injuries inworld-class volleyball. Br J Sports Med 2018;52(2):74-82.


Shutterstock.com #901718798

Participating in a yoga course decreased the number of falls reportedby older adults in a rural community in Wisconsin, according to newresearch published in December.

Past research on yoga in elderly populations found that yoga in-creases strength and balance—both associated with reduced fallrisk—but this is one of the first to draw a line directly between yogaand a decrease in the number of falls. The results appear in thejournal Complementary Therapies in Medicine.

First author Irene Hamrick, MD, Professor of Family Medicine atthe University of Wisconsin, and her collaborators enrolled 38 healthyadults older than 60 years in a free 8-week yoga course. Participantsattended two 1-hour classes a week over the course of the study.Classes included seated and standing yoga poses, breathing exer-cises, body awareness, and meditation.

“We adapted the poses to their ability,” Hamrick said, “and ad-vanced them as they were able to advance.”

During the 8 weeks, participants were also randomly assignedto either practice yoga for 10 minutes daily at home and do a 5-minute breathing exercise, or just perform the breathing exercise.

On surveys at the start of the study, 15 participants reported atotal of 27 falls in the 6 months prior. In a follow-up telephone surveysixth months after the start of the study, respondents’ reports showedthat, overall, the number had dropped significantly: During that time,13 participants reported a total of only 14 falls. Participants alsoshowed significant improvement on balance and strength tests be-tween the start of the study and 1 week following the 8-week course.

There was equal improvement between the group that practicedyoga at home and the group that did not, which Hamrick said is anencouraging sign for future application of yoga programs.

“Many times, in real life, patients won’t continue the exercises,”Hamrick said. “But just going to the class was enough to stimulatethe brain-to-muscle connection and reduce falls.”

Participants self-reported the falls measured in the study, whichraises questions about accuracy, noted Kristine K. Miller, PT, PhD,Professor of Physical Therapy at Indiana University. Miller was not in-volved in the study. “Falls are really hard to track,” she said. “Some-times people define a fall differently.” People also may not rememberall of their falls, or may be reluctant to disclose them all, she noted.

However, the decreased number of falls came alongside im-provements in strength and balance, which helps validate the reduc-tion in the number of falls. The findings are congruent, and they

Yoga reduces falls in older adults By Nicole Wetsman

Continued on page 12

in the moment: sports medicineContinued from page 11

12 01.18 lermagazine.com

Over the past 15 years, the incidence of anterior cruciate ligament(ACL) injury in children and adolescents has increased. And althoughthis population requires special considerations, in part due to theircontinued musculoskeletal growth, medical management of this con-dition varies widely. Toward this end, 71 orthopedic members of thePediatric Research in Sports Medicine (PRiSM) study group were sur-veyed to assess their medical management recommendations andassociated complications in pediatric ACL injury. The study was pub-lished in the February 2018 issue of the Journal of Pediatric Or-thopaedics.

For the 15-question survey, two scenarios were presented: an8-year-old child with a complete ACL tear and adolescent patientswith 2 years of growth remaining. Regarding the child, iliotibial bandreconstruction was recommended by 53% of respondents; all-epiphyseal reconstruction was recommended by 33%; but only 3%recommended bracing over a surgical intervention. For adolescentpatients, physeal “respecting” technique was recommend by 47% ofrespondents; physeal sparing intervention was recommended by31%; and 19% indicated they would perform an adult-style ACL re-construction (ACLR). Additionally, whereas growth disturbance afterACLR remains low, new cases continue to be reported.

In a related topic, a study published in the January 2018 issueof Knee Surgery, Sports Traumatology, Arthroscopy indicates thatmore than 90% of children and adolescents return to sport after un-dergoing ACLR. The researchers reviewed 20 studies comprising1,156 ACLR cases that met the inclusion criteria. The cohort had amean age of 14.3 years, with a mean follow-up time of 6.5 years. Therate of return to sport was 92% and the rate of return to preinjurylevel of sport was 78.6%. On final follow-up, however, it was notedthat this return to sport was associated with a relatively high rate ofreinjury, with graft rupture and contralateral ACL injury. Sources: Popkin CA, Wright ML, Pennock AT, Vogel LA, et al. Trends in management and com-plications of anterior cruciate ligament injuries in pediatric patients: a survey of thePRiSM Society. J Pediatr Orthop. 2018;38(2):e61-e65.Kay J, Memon M, Marx RG, et al. Over 90% of children and adolescents return tosport after anterior cruciate ligament reconstruction: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc. 2018 Jan 13. [Epub ahead of print]

iStockphoto.com 171577005

ACL treatment in children varies widely;

90% return to sport after ACLR

HIP STRENGTHENING optimizes PFP treatment

A study published in the January 2018 issue of the Journal ofOrthopaedic & Sports Physical Therapy presents new insights andevidence-based suggestions into the addition of hip strengtheningto knee strengthening for people with patellofemoral pain (PFP).Indeed, the combination of hip strengthening and knee strength -ening has shown to be superior to knee strengthening alone, ac-cording to the findings.

The authors of the study conducted a systematic review of14 trials comprising 673 subjects with PFP. They found that an in-tervention of hip and knee strengthening not only reduced painin the subjects but enabled them to return to physical activity.Moreover, benefits of hip and knee strengthening continued afterphysical therapy was completed. SourceNascimento LR, Teixeira-Salmela LF, Souza RB, Resende RA. Hip and kneestrengthening is more effective than knee strengthening alone for reducing painand improving activity in individuals with patellofemoral pain: a systematic reviewwith meta-analysis. J Orthop Sports Phys Ther. 2018;48(1):19-31.

support each other, Miller observed. Notably, she said, the averagescore on one of the physical assessment tests, the Dynamic Gait In-dex, jumped from 20 to 22; a score of 22 is the threshold indicatinga low risk of fall.

This study was not able to identify the role that meditation andthe breathing aspect of yoga played in fall reduction, although Hamricksaid several study participants mentioned that they appreciated de-veloping foot awareness as a part of balance during the yoga practice.Both she and Miller said that they hope to see more research workthat teases out the role of mindfulness and breathing.

“It might help folks have a little bit motor control and balancebecause they’re relaxed,” said Miller.

Hamrick noted that this particular study was done in a smallsample in a specific community and that more research in largergroups is needed to solidify the role that yoga might play in fall re-duction in the elderly more generally.

Other balance and strength exercise programs, like tai chi, havebeen shown to decrease the number of falls, as noted by a meta-analysis the Journal of the American Geriatrics Society. Hamrickhopes future research will help build up a similarly robust base of ev-idence for yoga.

“We’re trying to expand the repertoire of available coursesor activities that would be of value to our patients,” Hamrick con-cluded. Sources:Daubney ME, Culham EG. Lower-extremity muscle force and balance performancein adults aged 65 years and older. Phys Ther.1999;79(12):1177-1185.Hamrick I, Mross P, Christopher N, Smith PD. Yoga’s effect on falls in rural, olderadults. Complement Ther Med. 2017;35:57-63.Lomas-Vega R, Obrero-Gaitán E, Molina-Ortega FJ, Del-Pino-Casado R. Tai chi forrisk of falls. A meta-analysis. J Am Geriatr Soc. 2017;65(9):2037-2043.Ni M, Mooney K, Richards L, et al. Comparative impacts of tai chi, balance training,and a specially-designed yoga program on balance in older fallers. Arch Phys MedRehabil. 2014;95(9):1620-1628.

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People with PFP are less physicallyactive than healthy controls, withregard to both steps per day andminutes of mild, moderate, and intenseactivity. Increases in activity-relatedpain may cause patients to modifytheir lower extremity function duringtasks associated with physical activity.

PATELLOFEMORAL PAINMore activity means more pain—and then less activity?

By Neal R. Glaviano, PhD, AT, ATC; Andrea Baellow, MS; and Susan Saliba, PhD, MPT, Med

lermagazine.com 01.18 15lermagazine.com 01.18 15


It is widely accepted that engaging in regular physical activity is ben-eficial for promoting and maintaining overall physical health and re-ducing the risk of chronic disease and premature death. TheAmerican College of Sports Medicine and the Centers for DiseaseControl and Prevention have published guidelines on physical ac-tivity and public health that have been endorsed by the AmericanHeart Association.1,2 Healthcare professionals involved in testingand prescribing exercise accept these guidelines as preventivemeasures.

Recommendations are that healthyadults, 18 to 65 years old, engage in a mini-mum of 30 minutes of moderate-intensity aer-obic physical activity 5 days a week or aminimum of 20 minutes of vigorous-intensityaerobic activity 3 days a week, with an overallminimum of 10,000 steps per day.1 Recom-mendations also are available for increasingmuscle strength and endurance to promoteand maintain good health and physical inde-pendence.1

The benefits of participating in aerobicand muscle-strengthening physical activitiesare vast. They include promoting and main-taining skeletal health and reducing the riskof premature chronic health conditions, including thromboembolic stroke, hyperten-sion, type 2 diabetes mellitus, obesity, manycancers, anxiety, and depression.1 Engagingin extra weight-bearing activities and higher-impact activities such as stair climbing or jog-ging can further promote and maintainskeletal health.

These recommendations become prob-lematic, however, in populations of patientswho may be refraining from or limiting physi-cal activity because of chronic pain.

The impact of patellofemoral painPatellofemoral pain (PFP) is a chronic condition described as gen-eralized anterior knee pain during a multitude of activities, typicallybecoming worse with prolonged activity.3,4 Activities that induce orexacerbate pain include, but are not limited to, walking, jogging,squatting, lunging, kneeling, prolonged sitting, and walking up anddown stairs.5-8 Many of these activities are the same as those rec-ommended by the American College of Sports Medicine as waysto promote physical health and reduce the risk of morbidity. The sit-uation is problematic and paradoxical: People who have a chroniccondition—specifically, PFP—are limited in their ability to engage inactivities to benefit their overall health.

As many as 74% of adults with PFP decrease their activity levelor stop activities altogether because of pain.9 Rathleff and col-leagues10 also identified similar trends within an adolescent popu-lation: 71% of adolescents with PFP reduced or stopped sportsparticipation and decreased their leisure time each week, com-pared to both healthy controls and adolescents with other types ofknee pain.

These results are concerning. People with PFP have pain and

symptoms for many years following their initial diagnosis,10,11 and cur-rent conservative treatments are not always successful in producingpositive long-term outcomes.12 People with PFP who are unable tocomplete the recommended amount of physical activity because ofpain are at serious risk of poor overall health and morbidity.

Study and findings: General discussionWe designed a study to objectively evaluate physical activity levelsin people with PFP and compare those levels to physical activity lev-

els in people without PFP. We also analyzedour findings to determine if a relationship ex-ists between activity level and any of threesubjective measures:

• worse knee pain over the past 72hours, based on a visual analog scale(W-VAS)

• subjective function, based on the Ante-rior Knee Pain Scale

• fear avoidance belief, based on the FearAvoidance Belief Questionnaire physi-cal activity subsection.

We enrolled 40 total participants: 20people with PFP (15 females, 5 males; medianage, 22.2 [±2.6] years) and 20 healthy con-trols (15 females, 5 males; median age, 20.8[±1.8] years). Participants completed the threesubjective questionnaires and wore a wirelessmonitor over a 2-week period to collect dataon daily activity level, which was assessed byboth steps per day and minutes of mild, mod-erate, and high activity per day.

We found that people with PFP are lessphysically active than healthy controls. Thosewith PFP took 3400 fewer steps and com-pleted almost 1 hour less of physical activityeach day over the 2-week period. This hourof physical activity can be further brokendown to 40 fewer minutes of mild activity, 4

fewer minutes of moderate activity, and 10 fewer minutes of highphysical activity (Figure 1, page 18).

Among study participants with PFP, we also identified a positiverelationship between physical activity, defined by steps per day, andthe Anterior Knee Pain Scale. This finding suggests that people withbetter subjective function are also more active. We saw a negativerelationship between steps per day and the W-VAS and Fear Avoid-ance Belief Questionnaire; participants with a greater level of painwere less likely to be active, and those with more fear avoidancebeliefs completed fewer steps per day.

There were no relationships between the subjective scales andminutes of mild, moderate, or high activity. There were also no re-lationships between physical activity levels and subjective functionamong healthy controls.

The physical activity-pain relationshipin people with PFPThe etiology of PFP is unknown, but it has long been proposed thatone cause is increased stress on the patellofemoral joint. Excessive

Continued from page 15


istockphoto.com 592655170

physical activity might result in repetitive stress that exceeds thejoint’s ability to accommodate the load.13

There has been a recent increase in research evaluating phys-ical activity in patients with PFP to gain a greater understanding ofthe role of activity in the pathology of PFP and its influence on theindividual.10,14,15 Briani et al reported that women with PFP who weremore physically active also reported a greater level of pain (bothself-reported pain for the previous month and current pain level as-sessed in a laboratory setting).14 An intense level of physical activitypredicted almost one third of PFP cases, whereas a moderate levelof physical activity predicted only 1% of cases.15

These findings are different from those of our study, whichfound that greater knee pain in the previous 72 hours was associ-ated with less activity over the subsequent 2-week period. Althoughthere are methodological differences between the studies,14,15 it isimportant to consider that the directional relationship between ac-tivity and pain is unknown. It is plausible that people experiencinga greater level of pain might modify their activities to minimize sub-sequent pain. Within our study, we did find that elevated fear avoid-ance beliefs were also evident in patients who had a greater levelof pain and a lower level of physical activity.

Knee pain associated with an increase in activity provides somesupport for the theory that repetitive loading may be a factor thatcontributes to the presentation of pain in these patients. We havedata (in review) suggesting that less active women with PFP havealtered frontal-plane kinematics during common physical activitytasks, such as running, squatting, and stair ambulation. These

subjects presented with greater hip adduction and knee abduction,which has been linked to a greater level of pain and lower subjectivefunction.16,17 If these women participate in physical activity, therefore,altered mechanics might be responsible for increased pain. This be-comes a challenging “catch-22” for PFP patients: The prospect thatincreased physical activity will result in knee pain is as problematicas the prospect of physical inactivity, which can lead to decreasedhealth-related quality of life18 and increased risk of a myriad ofhealth conditions.19-22

Because a relationship exists between the level of physicalactivity and pain, it is important to evaluate the consequences ofpain during functional activities. Self-reported pain has been studiedduring specific functional tasks in patients with PFP,5,16,23-25 but theeffect of pain on neuromuscular measures during commonly per-formed physical activity tasks also must be evaluated.

Bazett-Jones and co-workers26 reported that increasing kneepain with repetitive single-leg squats was associated with a decreasein hip extensor strength and altered hip mechanics during running.Greuel and colleagues27 also found that increased pain has an in-fluence on running mechanics, specifically at the knee. Changes inlower-extremity function do appear to be relative to the magnitudeof pain reported by patients; Ott and colleagues28 found that womenwith PFP who reported more knee pain following aerobic exercise hada greater reduction in quadriceps activity than women who did nothave pain following aerobic activity and healthy controls.

The findings of Briani et al14 also support this change in quadri-ceps function, as PFP patients who were more active and experiencinga greater pain level had a delay in quadriceps activation during stairambulation. These changes in neuromuscular function have been hy-pothesized to be a compensatory strategy to reduce loading on theknee; however, given the chronicity of PFP, it is unknown how modifi-cations in lower-extremity mechanics contribute to long-term jointhealth and the potential risk of additional pathology.

Clinical interventionsEmploying interventions that decrease pain and improve individualimpairments for the patient is vital.29 Emerging evidence suggeststhat subgrouping patients with PFP may provide a more targeted in-tervention and improve outcomes, as opposed to treating all PFPpatients the same way.30 One of the challenges with PFP is the het-erogeneous presentation of symptoms and pain-provoking tasksfrom one patient to the next. This complicates the clinician’s abilityto prescribe recommendations for physical activity while minimizingpain.

To the best of our knowledge, no published studies have eval-



Figure 1. How intensity and duration of physical activity compares in study partici-pants with PFP and healthy controls



uated the effect of an intervention program specifically targetingphysical activity levels for PFP patients. However, a recent treatmentparadigm, RISK (Reduce overall load, Improve capacity to attenuateloads, Shift loads, Keep adapting to the runner’s goals and capacity),has been proposed for treating runners with PFP.31 Although thistreatment approach currently focuses on runners, the concepts be-hind it provide strong recommendations for treating other PFP pa-tients who have modified their activity level because of pain.

Reduction of load. Because pain contributes to altered lower-extremity mechanics, it is important to employ proper pain man-agement early to prevent potential consequences. Reducing theload is a common treatment for patients in whom PFP has been di-agnosed; a study in the United Kingdom of physiotherapists’ man-agement strategies for PFP found that a large number recommendthat their patients not participate in recreational or sporting activitiesif they experience any knee pain.32 This concept is also supportedby Dye and co-workers,33 who propose that tissue homeostasis ofthe patellofemoral joint is essential for patients with PFP. Patientsmust stay within their “envelop of function,” Dye advised, by mini-mizing activities that lead to increased pain and symptoms.33

Strength training. It is important, after reducing load, toprogress to a strength-training program to improve the capacity toattenuate the load on the knee joint. Both hip-focused and knee-focused strength-training programs have produced positive short-term outcomes with regard to both pain and subjective function.34-37

Shifting the load during common pain-provoking tasks shouldbe the next step. Gait retraining has produced positive improve-ments in running mechanics for patients with PFP, with short-termretention of beneficial improvements.38 Salsich et al39 also identified

improvements in lower-extremity movement and control followinga task-specific movement training program. This experience pro-vides support for individualizing treatment for PFP patients, basedon functional impairments that may prevent them from being phys-ically active.

Adaptation. The final step in the RISK paradigm is to have thepatient adapt to specific goals, which requires identification of thetypes of physical activity in which the patient aims to participate. Asrecommended by Barton,31 this step should include communicationbetween patient and clinician, and should be adjusted as symptomsand physical activity goals change.

ConclusionsPeople with PFP are less physically active than healthy controls, inregard to both steps per day and minutes of mild, moderate, and in-tense activity. Clinicians should be aware that increases in the activitylevel of patients with PFP may be accompanied by worsening kneepain, which may result in modifications to lower-extremity functionduring tasks often associated with physical activity. Assessing activitylevel and pain may provide valuable information when evaluating andtreating patients with PFP. Additional research in understanding ac-tivity modification within this population is warranted.

Neal R. Glaviano, PhD, AT, ATC, is Assistant Professor in the Schoolof Exercise and Rehabilitation Sciences, University of Toledo, Ohio.Andrea Baellow, MS, is a doctoral student and Susan Saliba, PhD,MPT, MEd, is Professor, both in the Department of Kinesiology atthe University of Virginia, Charlottesville.

References are available at lermagazine.com.


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The effect of copper-impregnated socks on tineapedis in football players

In a study of collegiate football players, whoare at high risk of tinea pedis due to theirtraining environment, copper-impregnatedsocks were associated with a high rate oftinea pedis symptom resolution and a lowrate of new cases—supporting claims of thesocks’ antifungal potential.

By Gary M. Rothenberg, DPM, CDE, CWS

Tinea pedis, or athlete’s foot, is one of the most common pedal der-matologic skin complications. Worldwide, 70% of the populationwill be infected with tinea pedis at some time.1 This dermatophyticinvasion of the skin’s stratum corneum usually is transmitted by di-rect, person-to-person contact. Many populations can be consid-ered at high risk of tinea pedis, including the immunocompromised(such as people with diabetes or who take a corticosteroid chroni-cally), athletes, and members of the military.

Diagnosis of tinea pedis is usually clinical, based on location;the patient’s complaints of itching and burning; an appearance ofdryness, scaling, and blistering; and significant, persistent macera-tion of the interspaces. For many clinicians, diagnosis is made basedon signs and symptoms alone, at which time empiric treatment fortinea is initiated. Confirmation of the diagnosis can be made usingdirect microscopy of skin scrapings exposed to potassium hydrox-ide (KOH prep) or by fungal culture, but a negative KOH prep ornegative fungal culture does not always exclude symptomaticpathology.

In 2002, Cohen and colleagues published data on an Athlete’sFoot Severity Score (AFSS) that is based on a clinical diagnosis oftinea pedis in 224 soldiers in the Israeli Defense Force.2 The AFSSwas designed to assess tinea pedis in a military setting, as an ath-letic trainer might use a similar tool to evaluate athletes. The AFSSclinical examination yields a numerical score after 1) evaluating forerythema and scaling and 2) documenting the number of involvedinterspaces. Higher scores signal the potential for complications oftinea pedis, leading the investigators to propose risk modifiers fortinea pedis among the soldiers.

Management of tinea pedis, which includes topical agents (assprays, creams, and gels), oral antifungals, and home remedies, canbe challenging.3-5 The fungal infection causes increased basal-cellproliferation, epidermal thickening, and scale formation. Left

Copper-impregnated socks worn duringtraining have potential to treat or preventfungal infection of the foot among athletes,this early case series trial shows. Furtherstudy of the garments’ efficacy is warranted.

Istockphoto.com 483769134



untreated, tinea pedis can progress, and the patient may experiencebacterial superinfection, leading to significant complications.6

Copper and its disinfecting abilityThe antimicrobial and antifungal benefits of copper were first iden-tified by the ancient Greeks, who recognized the metal’s natural dis-infecting properties on liquids, solids, and human tissue. Becauseof these characteristics, copper remains a commonly used elementin currency, industry, and medicine today. Peer-reviewed studieshave demonstrated copper’s antimicrobial efficacy against a widevariety of bacteria, influenza A virus, adenovirus, and fungi.7

In the past few decades, soft, malleable copper has been em-braced by the textile industry in the form of copper-impregnatedclothing, including socks. In 2008, Zatcoff and colleagues8 studied56 patients with diagnosed tinea pedis who wore copper-impreg-nated socks for as long as 6 weeks. The majority of participantsdemonstrated improvement in symptoms, and none experiencedadverse reactions to the copper oxide. In 2007, socks containingcopper were provided to trapped Chilean miners prior to their res-cue to assist in reducing the presence of, and infection by, fungi.9

It is generally believed that athletes are at particular risk of de-veloping tinea pedis. Environments in which many athletes train andparticipate potentiate their exposure to the fungus (usually, Trichophyton rubrum) and promote its transmission and growth.

Contributing factors include occlusive shoes, excessive sweating(leading to moisture build-up, shear, and friction), and sharedshower and locker room floors. Pickup and colleagues10 reporteda 69% incidence of fungal infections among male professional andcollegiate level soccer players, compared with a 20% incidence innon-athletes.

Given this high rate of occurrence of tinea pedis among ath-letes, and the fact that, regardless of level of participation, fungal in-fections can cause them to miss time in training and competition,the author’s study described here sought to gain knowledge of, andexperience with, the use of copper-impregnated socks during thepreseason training camp for a collegiate football program. The studydesign is a large case series undertaken for both quantitative andqualitative results. Additionally, the trial was set up to mimic a real-world scenario, including diagnosis made based on clinical symp-toms alone, as is often done by podiatrists and athletic trainers.

Materials and methodsThe copper-impregnated sport sock utilized in this study has the tech-nology incorporated in the boat or along the foot region of the sock(Figure 1, above). The technology is a proprietary, protected blend ofcopper-based compounds that is permanently and homogenously in-troduced throughout the yarn during production. This technology can



Table 1. Demographic profile of study subjects

Age 21 years (mean)

Sex 100% male

Ethnicity

Black/African American 65%

White 23%

Asian 0

American Indian 0

Native Hawaiian or Pacific Islander 0

Hispanic/Latino 0

Other 12%

Table 2. Outcomes at Week 4 and Week 8 for players

with tinea pedis symptoms at Week 1Subject Week 1 Week 4 Week 8

1 TP TP DC

2 TP TP NTP

3 TP NTP NTP

4 TP DC DC

5 TP NTP NTP

6 TP NTP NTP

7 TP TP TP

8 TP NTP DC

9 TP TP TP

10 60 DC DC

Key: TP, tinea pedis symptoms; NTP, no tinea pedissymptoms; DC, discontinued from study.

be either low load or high load, depending on the final concentration of the blend and its desired at-

tributes. The copper-enhanced sport sock in this study featured low-load technology.

The study population was male collegiate football players at a single university-based presea-

son training camp. All athletes were older than 18 years; none had known sensitivity to copper.

The study was approved by an independent institutional review board, and all eligible athletes gave

informed consent to participate in the study.

Through the team’s equipment manager, players were issued study socks for use during all

practices. After each practice, thesocks were returned, laundered, andreplaced with another pair of studysocks for the next training session.

Players were examined at enroll-ment as well as after 4 and 8 weeksof wear/training. Follow-up sessions at4 and 8 weeks were performed aftera day’s training; the players’ atten-dance was requested but not manda-tory. Physical examination was per-formed by the author (a podiatricphysician), including clinical assess-ment for potential tinea pedis andother skin manifestations, along withphotographic assessment. As in theAFSS protocol described above, theauthor presumed the diagnosis oftinea pedis based on subjective re-porting of itching in the presence ofobserved plantar skin erythema andscaling or interdigital maceration. Forqualitative data purposes, the playerscompleted a questionnaire to assesstheir experience with the trial socks,including self-reported perceptions ofcomfort, foot appearance, odor, andperformance while wearing the socks.



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ResultsTable 1, page 22, shows the demographicsof the study participants. Of the original 52players enrolled, 17 were lost to follow-upduring the trial, leaving complete data for 35athletes. The incidence of tinea pedis in thisstudy population was found to be 19% atbaseline (10 of 52 participants) and declinedto 9% (3 of 35 participants) at the 8-week follow-up.

Of the 10 participants who had clinical signs of tinea pedis footat baseline, five were negative for podiatric assessment of tineapedis by Week 8; three discontinued the study; and two did not ex-perience resolution of the symptoms of tinea pedis. Conversely, onlyone player without clinical signs of tinea pedis at baseline devel-oped symptoms during the study period. The incidence of dry skinfor the group was 54% at trial initiation and 43% at Week 8.

A questionnaire was used to gain more knowledge regardingthe athletes’ self-reported experience utilizing the test sock. Partic-ipants were asked about their perceived performance in relation towearing the socks. The questions asked were:

• “Were you able to physically accomplish more?” (51% responded “Yes”)

• “Was your recovery rate improved?” (37% responded “Yes”)• “Was your on-field performance improved?” (31%

responded “Yes”)On a scale of 1 to 10 (10 being highest), the participants gave

the socks an overall average satisfaction rating of 8.0 at Week 8.No adverse events were reported during the study period. No play-

ers experienced a sensitivity or allergic-type ofreaction to the socks.

DiscussionIn today’s health-conscious environment, phys-ical exercise is recommended, and everyonewho exercises is at risk of fungal infection ofthe feet. Fungi are ubiquitous, and any minorincident (such as shear and friction in a shoe)

can create a portal for a fungus to infect and reproduce within theskin layers of the foot. Collegiate and competitive athletes remainat extremely high risk of tinea pedis because of the moisture cre-ated from sweating, occlusive shoe gear, and shared showers orlocker rooms. Adherence to prescribed topical antifungal medica-tions can be inadequate for healing, especially among college-agedmen and women.

The presumed initial incidence of tinea pedis among our studypopulation (19%) was consistent with the reported incidence in thegeneral population, but not as high as has been reported amongathletes.10 Utilization of the enhanced athletic socks appears to havehad an influence on the treatment and prevention of tinea pedisfoot symptoms and clinical findings in this group.

Of the 10 participants with suspected tinea pedis at baseline,eight completed Week 4 of the study; symptoms had resolved infour players and remained unresolved in four more. Six of those ath-letes completed Week 8 of the study; symptoms had resolved infour and were still suspected in two. Of the four players whosesymptoms had resolved at Week 8, only one had exhibited symp-



Figure 1. Study sock

toms at Week 4. These data are summarized in Table 2, page 22.It must be noted that two athletes who reported symptoms at

baseline continued to do so at Weeks 4 and 8; however, both notedthat they had not complied with instructions to wear the socks dailyduring the trial. The player who was negative for tinea pedis symp-toms at Week 1 but positive for tinea pedis at Weeks 4 and 8 alsoreported less-than optimal-compliance. The potential to prevent losttime preparation for, and participation in, athletic activity may there-fore be significant.

The results of the qualitative questionnaire suggest that the ath-letes had, overall, a positive experience with the socks. Many saidthat they believed their performance had improved because of thesocks. There may be a psychological component to being enrolledin a nonblinded clinical trial and being queried about the experiencebut, nonetheless, the simple addition of unique socks to a trainingprogram was associated with a positive outcome for the majority ofplayers, in terms of the clinical and nonclinical parameters studied.

Limitations and conclusionsThis trial studied only football trainees at a single university locatedin one geographic area; results might not be generalizable to otherathletes or other geographic regions. Another potential limitationof the study is that tinea pedis was not confirmed using a KOH prepor fungal culture. Nevertheless, the diagnosis of tinea pedis basedon clinical signs alone is consistent with common practice.

Between May 29, 2016, and June 4, 2016, an online poll byPodiatry Management asked the publication’s more than 17,000subscribers “How do you diagnose tinea pedis in your practice set-

ting?” and offered respondents a choice of three answers.11 Therewere 681 responses:

• 73.42% chose “Clinical symptoms (including itching, scaling,interdigital maceration, etc) only”

• 25.70% chose “Clinical symptoms and laboratory diagnos-tics such as KOH prep or fungal cultures”

• 0.88% chose “Laboratory diagnostics such as KOH or fungalcultures only”:

Findings of the poll suggest that using a clinical definition oftinea pedis in our study would mimic real-world experience for anathletic trainer who does not have formal medical training managinga group of athletes. Rarely are KOH preps or cultures taken in theusual setting, suggesting that many athletic trainers must rely solelyon the appearance of the foot and the athlete’s symptoms to em-




pirically treat a fungal infection. Because topical treatments for tineapedis are available over the counter, most athletic trainers will makean assessment of tinea pedis and recommend topical therapy. Ad-mittedly, itching, scaling, and interspace maceration alternativelycan be an inflammatory manifestation, including dermatitis andeczema, rather than a fungal infection.

Another limitation of the study was that the enhanced sockswere worn only during training practices. Adherence was not ac-tively monitored outside of scheduled training times. It can be hy-pothesized, however, that even better results than what is reportedhere would have been observed had participants wore copper-im-pregnated socks at all times.

The specific antifungal properties of high-load copper-embed-ded materials technology have subsequently been demonstrated

in unique EPA registrations for a textile that can kill 99.9% of tineapedis fungi after 12 hours of contact with the textile.12,13 These reg-istrations utilize a higher concentration of the technology than uti-lized in the socks worn this study—and, presumably, would beassociated with even more highly positive outcomes.

To our knowledge, this is the first case series of athletes utilizingcopper textile technology to prevent foot complications in an at-riskpopulation. Despite the lack of confirmation of tinea pedis amongstudy subjects by laboratory testing, data presented here have prac-tical, real-world implications. The results of this trial warrant furtherinvestigation and show that a nonpharmacotherapeutic manage-ment strategy has the potential to treat or prevent fungal infectionof the foot among athletes.

Gary Rothenberg, DPM, CDE, CWS, is a podiatrist and Assistant Pro-fessor of Internal Medicine in the Division of Metabolism, En-docrinology, and Diabetes at the University of Michigan MedicalSchool, Ann Arbor.

Acknowledgements: The author thanks Steve Walz, Associate Athletic

Director and Director of Sports Medicine at the University of South

Florida, Tampa, and Jeremy Lees, Equipment Manager of the University

of South Florida football team, for their support and logistical planning

of this trial. Chesapeake IRB approval Pro00007188 provided ethical

consent.

Disclosure: Financial support for the trial was provided by Cupron Med-

ical (Richmond, VA) and Under Armour (Baltimore, MD). The author has

served as a consultant both for Cupron Medical and Under Armour.

References are available at lermagazine.com.


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Saying ‘PTTD’ is misleading:It’s time for a new lexicon todistinguish pathologies

The author applies his experience design-ing ankle foot orthoses to propose that, in-stead of using diagnostic language todescribe medial column ligamentous fail-ure, practitioners learn a new, descriptivelanguage to understand the nature of apatient’s pathology. Beyond that, he pro-poses causality due to ligament failure.

By Ian Engelman, MS, CPO

Have you read Outliers: The Story of Success by Malcolm Gladwell?In the book, he observes that expertise is developed through tenac-ity and repeated observation and presents examples of what hecalls the “10,000-hour rule” for mastering a craft or field of inquiry.1

I mention this because, over the past 15 years, I have designedmore than 15,000 ankle–foot orthoses by working with 3-dimen-sional plaster models. Each model takes, on average, 1 hour tomake—causing some practitioners to burn out. I have remained inthe plaster room, however, and, although I don’t pretend to com-pare myself to the leaders described in Outliers, I have put in mytime and therefore have insights to share.

In this article, I present a perspective on, and a theory of, me-dial column breakdown (ie, ligamentous failure), based on observa-tion and experience, in the hope that data and statistical analysiswill follow. Using CubeVue software to process imaging acquired bythe pedCAT ultra-low dose computed tomography system (bothproducts of Curvebeam, Warrington, Penn.), I believe that scientificanalysis of these injuries is possible through repeatable quantifica-tion—perhaps for the first time.

A few words about the language we speakThe interaction between thought and language is well studied. Alinguist can explain how language can limit our thoughts and un-derstanding: Sometimes, it takes a new language and a new tool tobreak through these limitations. Three-dimensional rendering thusreveals shortcomings of previous 2-dimensional analyses and leadsto new definitions.

The old language can restrain perspective and lead us in the

Some medial column ligamentouspathologies aren’t well explained by oldterminology, such as “posterior tibial tendondysfunction.” Moreover, those pathologiesseem to fall into distinguishable categoriesnot delineated by the current lexicon.

wrong direction—here, in part, as a result of using words that de-scribe medial column ligamentous failure in a diagnostic fashion.Look at the following listing; which word or terms do you use to de-scribe this common pathology:Medial instability? Ligamentous lax-ity? Or adult-acquired flat foot, hypermobility of the first ray,excessive pronation, fallen or collapsed arches, internal rotary dys-function, posterior tibial tendon dysfunction (stages 1-4), posteriortibial tendonitis, equinus, pes planus, equinovarus, pes planovalgus,or midfoot collapse?

Orthopedists, podiatrists, orthotists, physical therapists, andothers might use slightly or substantially different words or terms,but each language imposes limitations on understanding.

Perspectives on ‘medial column breakdown’Different professions have their own view of the pathology that Ipropose we generically call medial column breakdown (Figure 1).

Orthopedic surgery. Two common terms are hypermobility ofthe first ray and adult acquired flat foot. In addition, pathology is dis-cussed in terms of stages (1, 2 ,3, and 4). True, the degree of medialcolumn breakdown can vary, but the language of stages is littlemore than a subjective label of the degree of deformity, saying noth-ing about the location of the failure or the type of pathology of thefoot—for example, failing to speak to hind-foot or midfoot participa-tion.

For me, hypermobility of the first ray is an odd way of lookingat a failure that is somewhere along the medial column. I agree,however, that there would be increased relative collapse as a sec-ondary effect of greater-than-normal mobility of the first ray. Afterall, the first ray is a substantially weight-bearing element.

Podiatry. “Posterior tib” is the shorthand I hear most often. Thiscatch-all seems to mean posterior tibial tendonitis or posterior tibialtendon dysfunction. The words lead the mind to think that thecausality is weakness of this particular tendon/muscle, and that this

one muscle suspends the whole medial column! That view seems incomplete. Although there can be pain

around the posterior aspect of the medial malleolus, such cases are(in my experience) in the minority. Moreover, it seems unlikely thatmuscles are responsible for the structural stability of the medial col-umn. The human body naturally finds ways to save energy, and firingmuscles to keep the medial column from collapsing is an inefficientuse of the body’s resources.

Orthotics and prosthetics. In school, pes planovalgus is taught.True, medial column breakdown often has hind-foot valgus, but not inevery case. Another favorite closed kinetic-chain description is internalrotary deformity. For some of these cases, there is no obvious tibialinternal rotation, yet there are features such as forefoot abduction andhind-foot valgus. In short, it seems clear that not all of these casespresent with tibial rotation, and that those that do might not present




Figure 1: Three categories of ‘medical column breakdown’

Figure 1. Three categories of ‘medial column breakdown’

Figure 2: Ligaments are primarily responsible for the structure of the foot

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with the complete set of corresponding deformities.Physical therapy. Flat foot, pronation, and midfoot collapse are com-

monly used. These are generic descriptions readily understood by the pro-fessional and nonprofessional alike. The terms are useful in a general sense,but have limitations in that they suggest that the “whole” foot has failed.

Stating the organizing principleBetter and more specific terms lead to better, more specific understandingof the origin of the pathological condition. Efforts to describe the mecha-nisms of the foot and ankle joints often lead to comparisons with everydayarticulated elements. I’ve heard these mechanisms described as a hinge, aset of hinges, a sling, a kinetic chain, a mechanical bridge, a 3-legged stool—even a gyroscope! Such comparisons might be helpful to some, but I seeno point. Why compare? Instead, I believe we have the capacity to think directly about the bony segments with articular surfaces connected by ligaments.

In the spirit of looking at the medial column pathology in a new way,and for this exercise of experimenting with new language, put aside the oldterms and consider a set of more refined, specific terms that connect thecategories of medial column breakdown with failure in a specific ligament.The primary assumption is that the architecture of the medial column of thefoot is primarily held in position by ligaments that connect bones (Figure 2).Proximally to distally, the major ligaments involved are the deltoid, spring,cuneonavicular, and tarsometatarsal. Again proximally to distally, the bonesare the tibia, talus, navicular, cuneiform, and metatarsal.

I propose that failures of these ligaments are the primary contributors



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Figure 3: Normal foot

to medial column breakdown, but are by no means the only structural connections. It is also possible that breakdown of the lateral column willaffect the shape of the foot and lead to a condition that mimics medialcolumn breakdown.

Three-dimensional analysisNew tools enabled by 3-dimensional rendering provide the possibility ofa paradigm shift in understanding the interactions of bones with their ar-ticular surfaces. The most advanced system available is PedCAT, describedearlier. The technology of this imaging system is superior to others for aprofoundly important reason: The image is taken during weight bearing.This is critical for practitioners who want to understand and to help peoplewalk, because ambulation is, after all, a weight bearing activity.

Information about the relationships among the bones of a hangingfoot, for example, is not particularly helpful; this forces the practitioner toguess how those bones might line up during weight bearing. More pro-found analysis is the ability to scan in real-life conditions.

The foot will present in one way on a flat surface and slightly differentlyin the curved condition of a shoe. Currently, there is a habit of scanningon a flat surface. Evaluation during single-limb weight bearing in a shoe,with a foot orthotic, or inside an ankle foot orthosis would be the most rel-evant. Even better would be to somehow mimic the increased forces pro-duced in ambulation. For now, however, these 3-dimensional scans are soprofoundly better than 2-dimensional radiographs that, first, they are re-defining all the metrics and, second, important new parameters are being,



Figure 4: Lateral foot dislocation

and will continue to be, created.Many validation possibilities could lead to quantification and ef-

ficacy of treatment. For now, I’ll keep the focus on a better under-standing of medial column breakdown by looking closely at wherethe failure might be.

The word “failure” is used in this article, but any of the followingpossible ligamentous conditions could be substituted: stretched, at-tenuated, degenerated, partial tear, complete rupture, or a combi-nation of any of these. In examining more than 15,000 plastermodels, I’ve noticed shapes/pathologies that repeat themselves.These are pathologies that are not well explained by the old lan-guage, and they seem to fall into distinguishable categories.

New words to describe categories of pathologyUsing CurveBeam technology, it is possible to manipulate imagesto strip away (virtually) muscle and soft tissue from a sample fromeach category. With careful examination, it becomes apparentwhere the failure is likely to be. From its location, we can pinpoint asuspicious ligament.

The exercise of distinguishing categories forces one to labelthose categories. I’ve created 5 labels and their corresponding lig-ament (plus 1 label for the normal foot):



Figure 5: Talar escape

Normal foot (no ligamentous problems). Space limitationsprevent me from showing all the angles and internal alignments ofa normal foot. I present it here (Figure 3) because, if we are goingto investigate pathologies, we first have to agree on what a normalfoot is:

• From the sagittal view of the medial column, a relativelystraight line originates from the center line of the talus and runsthrough the navicular, medial cuneiform, and the shaft of the firstmetatarsal to the first metatarsal head.

• From the coronal view, the weight line from the center lineof the tibia drives straight through the talus, and the calcaneus issubstantially underneath.

Next, starting proximally and working distally: Lateral foot dislocation (deltoid ligament failure). Weakness

in the deltoid ligament presents with a foot shape that looks like thefoot is dislocated laterally from the weight line (Figure 4). The trian-gular shape of the deltoid ligament connects the tibia to 3 tarsalbones individually: the calcaneous, the talus, and the navicular. Incases like these, alignment of the medial column can be healthy,



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Figure 6: Mid-column collapse

but there is increased demand on it structurally because the lateral columnis no longer weight bearing. Valgus of the hind-foot is a feature in this cate-gory, but forefoot abduction may not present.

Talar escape (spring [plantar calcaneonavicular] ligament failure). Thespring ligament connects the calcaneus to the navicular in a way that holdsin the talar head. If this is stretched, the resulting opening becomes largeenough for the head of the talus to emerge (Figure 5). This deformity is easyto identify because there is a bony protrusion that is closer (approximately 3cm) to the medial malleolus than the navicular (approximately 5 cm). Withthis weakness, the talus rotates inward along with the ankle mortise. Hind-foot valgus and forefoot abduction often result.

Mid-column breakdown (plantar cuneonavicular ligamentous failure).This category seems to be the most common type of medial column break-down. The ligament that connects the medial cuneiform and the navicular islikely compromised. It’s hard to show in these 2-dimensional images (Figure 6)but, with 3-dimensional rendering and careful rotation, you can see gappingbetween these 2 tarsals. The declination of the talus points through the nav-icular but not to the cuneiform. It’s as if the linear line of segments breaks atan upward angle from which the rest of the bones align on a new straightline directed to the first metatarsal head.

Lisfranc breakdown (plantar tarsometatarsal ligamentous failure).This pathology is noticeably different than the others. The plantar ligament thatconnects the medial cuneiform to the first metatarsal is damaged (Figure 7).These 2 bones are relatively bulbous and leave an unmistakable bulge onthe plantar surface. It is interesting that there is often tolerable weight bearinghere, and that the foot can develop a fat pad not unlike the one under the



Figure 7: Lisfranc breakdown

calcaneus. Alignment and stability proximal to the “break” can be in thenormal range.

Lateral column flat foot (long [and short] plantar ligamentous fail-ure). This condition does not seem to be a failure of the medial column atall. When the foot is examined, we see good, healthy alignment of the me-dial column from sagittal and transverse viewpoints. In the coronal plane,the talocrural joint lines up over the calcaneus in a stable way. On exami-nation however, there is undeniable flatness (Figure 8). Perhaps the liga-ments supporting the lateral column are compromised in these cases (longand short plantar). In my experience, there are few functional issues fromthe reports of patients whose foot presents this way.

About imagingSevere limitations exist in communicating and distinguishing the categoriesreviewed in this article because we have only words and 2-dimensionalimages. The experience of 3-dimensional shapes rotating in space affordsa deeper understanding of the pathologies. CubeVue software can stripaway soft tissue (because it is less dense) to reveal bony substructure. Pul-sating between the exterior shape and the interior architecture allows theuser to fix their eye on (for example) a prominence and confirm internalanatomy.

Videos available at www.medialcolumnbreakdown.com attempt toshow the power of this new technology. I say “attempts” purposely. Thehuman brain has a direct line communication with the hands. Ideally, wewould have life-sized models in our hands so that each of us could rotateand examine them simultaneously. This ideal method of communication


Figure 8: Calcaneal plantar-flexed flat foot


puts the brain in a more active state and allows even more com-prehension. Close approximation is achieved by a first-hand user ofCurvebeam with Cubevue: The user with a mouse in hand can vo-litionally rotate an image in space.

For now, without having the Cubevue program in your hand,watching someone else rotate the object is the best we can do. A picture is worth a thousand words; so, what is a video worth?Here is a best-to-worst list of communication modalities:

• text/words• picture• video of a 3D-rendered image, rotated• 3D-rendered image, volitionally rotated by the viewer• 3D physical model in hand.

In conclusionIn my view, the ultimate analytical endpoint is a segmented modelconstruct produced by a program like SolidWorks (Dassault Sys-tèmes, Waltham, Mass.) that has virtual embodiments with the exactproperties and shapes of bones and ligaments. Such a model wouldallow any theory to be tested using computer-generated forces.Vectors could be applied with changes in magnitude and directionthat mimic stance phase. Computer analysis of emergent patholo-gies could be modeled by observation of the results that emergefrom a virtual weakening of specific ligaments.

Hoping to move the field in that direction, I’ve developed a theorythat is based on common sense and insights from my experience.

The concept of distinguishing categories is an academic exer-cise that helps us understand the root cause of the types of medial

column breakdown that we see in our practices. I’ve made a pointhere of finding examples that highlight and demonstrate failure of aspecific ligament; I am not suggesting that all pathological feet bepigeonholed in one of these descriptions. When evaluating a footwith medial column breakdown, I find it useful to keep these distin-guishing categories in mind. In many cases, there seems to be aprimary ligament and a corresponding shape involved in the pathol-ogy; in some cases, it is a combination of two or more failures.

I conclude with four ideas: • The goal of the practitioner should be to have a deep under-

standing of the problem at hand. That deep understanding thatmakes the best solutions possible.

• Instead of using diagnostic language to describe medial col-umn breakdown, I propose a new language that is descriptive.

• The architecture of the foot is primarily due to the ligaments,not the tendons.

• There is an important paradigm shift happening that vastlyimproves our understanding of these pathologies when we movefrom 2-dimensional radiographs to 3-dimensional rendering.

Reference: Gladwell M. Outliers: the story of success. Boston, Mass.: Lit-tle, Brown and Company; 2008."

Ian Engelman, MS, CPO, developer of the patented Blaze MI AFOfor medial column breakdown, is owner and president of InsightfulProducts, LLC. He also developed the Step-Smart Brace for dropfoot and the Funnel shoe horn.

Figure sources: Figures 1 and 2 supplied by the author. Figures 3-8 sup-plied by the author using CubeVue software (Curvebeam).

Disclosure: Insightful and Curvebeam collaborate to advance under-standing of foot and ankle biomechanics. Neither Insightful Products norIan Engleman have any financial relationship with Curvebeam.



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Promoting postsurgicalweight loss and activity toaddress joint pain

Strategies to help patients lose weightand become active after surgery need tobe individualized, multifaceted, and re -inforced long-term.

By Keith Loria

Many people who suffer from chronic joint pain are unable to exer-cise; as a result of this inactivity, they gain weight, which only in-creases their joint pain. To end this cycle, therefore, it only makessense that having surgery to relieve that pain will help patients bemore active and lose weight.

Surprisingly, this does not happen as often as one would think:Even after surgery, many patients choose not to exercise. That leadsto an increased risk of implant failure or development of pain inother joints than if they had been able to decrease their body massindex (BMI) after the initial surgery.

Webb A. Smith, PhD, clinical exercise physiologist at Le Bon-heur Children’s Hospital, Memphis, TN, noted that, after recoveryfrom surgery, pain is generally reduced but behaviors and habitspresent before surgery largely persist. Although there are excep-tions to this phenomenon, on average, patients end up with lesspain but the same sedentary behaviors and habits.

“Being obese increases risk of developing and progression ofosteoarthritis,” Smith said. “The trouble is that many of the factorsthat lead to obesity—Western diets, sedentary behaviors, and lowamounts of physical activity—are also problematic with respect toosteoarthritis. This makes the treatments for obesity and osteoarthri-tis very similar with respect to lifestyle and behavioral change.”

In addition, although patients identify joint pain and reductionin activity as reasons for weight gain, the causality of this relationshiphas been difficult to evaluate because most patients are alreadyobese at presentation of joint pain and most don’t lose weight after.

Christine Pellegrini, PhD, assistant professor of exercise scienceat the University of South Carolina’s Arnold School of Public Health,said behavior change is difficult: Before surgery, many patients areinactive because of pain and physical limitations.

“Patients are likely to try multiple different treatment optionsbefore turning to surgery, which means that this pattern of inactivitycould be happening for many years,” she said. “After the surgery,patients are likely to have better function and less pain but, becausethey’ve spent many years being inactive, it’s hard to quickly switchback to a more active lifestyle.”

James R. Hanna, DPM, of the New York State Podiatric Medical


It makes sense to have surgery to relieve pain so that patients can be more active and lose weight.But many choose not to exercise post operatively—leading, unnecessarily, to an in creased risk ofimplant failure or pain in other joints.


tients who are obese may also have poorer functionaloutcomes after undergoing knee replacement.

When patients have surgery, they typically attendphysical therapy, which focuses on increasing range onmotion and strength, mostly in the leg that was surgi-cally repaired. Smith said the recovery period after sur-gery is marked by a high amount of sedentary time,which is necessary to protect the repaired area andallow recover from surgery. However, this leads to de-conditioning of the whole body and, possibly, strengthimbalances.

“The surgically repaired leg is treated in physicaltherapy while the rest of the body may not be chal-lenged to the same degree,” Smith said. “Patientsmay feel better and pain free but, without a treatmentplan, this can mean that more pressure is placed onthe rest of the body that was not repaired. This leadsto frustration with treatment and may be discourag-ing.”

Not surprisingly, this situation reduces the pa-tient’s commitment to future physical therapy inter-vention and exercise in general.

The weight loss program at Pellegrini’s facility,modeled after evidence-based programs and mod-

ified based on patient input, includes numerous behavioralstrategies to help patients modify their diet and physical activity.

“We included regular calls, either weekly or every other week,to set goals and problem-solve around barriers patients were ex-periencing,” Pellegrini said. “Participants were en - couraged to tracktheir diet, physical activity, and weight loss throughout the program,using paper diaries, a website, or activity monitor like Fitbit. We pro-vided educational materials that discussed topics like how to eatfewer calories, how to be more active, and how to prevent a relapse.We also sent patients text messages three times a week to provideencouragement, tips, and reminders.”

Three studies offer insights on overcoming barriers to weight lossMost research shows that the primary barriers to activity includepain, physical limitations such as loss of range of motion, stiffness,and fatigue, and a lack of motivation. It is likely that some of the painand physical limitations would decrease over time, but patients maystill experience a lack of motivation to exercise, similar to the restof the population.

Assessing physical function and activity in obese patientsafter total knee arthroplasty.Webb A. Smith was lead author on astudy of physical function and activity in obese subjects who hadundergone total knee arthroplasty, focusing on their abilities andquality of life after having completed standard medical treatmentsand were released to resume normal activities.1 The study evaluatedpatients one year after knee replacement and put them through aphysical fitness assessment that measured parameters such as mus-cle strength, walking endurance, and range of motion in the knee.Researchers also asked study participants about their perceptionsof knee pain, function, stiffness, and health-related quality of life.

“We found that pain had improved in most patients but theywere still highly sedentary with no patients reaching recommended




Association, said many people are “creatures of habit,” and that anintervention such as surgery that alleviates pain merely allows themto go back to the lifestyle to which they’re accustomed—often,lifestyle habits that led to chronic pain in the first place.

“An inability to manage BMI after surgery certainly increasesthe risk for implant failure and progression of degenerative joint dis-ease,” Hanna said. “Other challenges to a person’s health from anelevated BMI are manifold. These include the development of type 2diabetes mellitus, cardiovascular disease (often complicated byhyper lipidemia associated with elevated BMI), and hypertension.”

Fear of re-injury can, of course, be a roadblock to assuming amore active lifestyle, but Hanna believes that proper education bythe physician or surgeon, as well as comprehensive physical ther-apy, can help ease the post-surgical transition and allay these fears.Group exercise, bringing together patients who are at in a similarpoint in their recovery, can be useful as well.

Mary E. Sanders, PhD, ACSM-RCEP, CDE, FACSM, clinical ex-ercise physiologist and adjunct professor at the School of Commu-nity Health Sciences, University of Nevada, Reno, noted obesity andpoor health increases the risk of any surgical procedure, and herclinic requires that patients attend a special “boot camp” before theagree to undergo a procedure.

“Bariatric surgery is complicated, expensive, and people needto qualify,” she said. “Bariatric patients had to complete a 12-weekweight loss, behavior change program to demonstrate their abilityto lose weight (5% or more) and increase physical activity and con-trol their diet in line with what their new eating pattern will be post-surgery in order to qualify for surgery.”

Challenges of losing weightPost-surgically, obese and inactive patients often have a higher riskof implant failure and pain in other joints than if they had been ableto decrease their BMI right after surgery—just one of the many chal-lenges that result from this. Some research has suggested that pa-


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levels of physical activity,” Smith said. “We also found that,compared to the population of people their age, that mosthad physical fitness deficits. My key take-away from thiswas the patients were not able to do the same activitiesas their peers and were missing an opportunity to im-prove these deficits with exercise. By not taking advan-tage of the exercise, they were not getting the most outthe surgery and were not recovering to their fullest po-tential.”

Importance of podiatric services. Podiatry is a keycom ponent to improving the quality of life for obese pa-tients. The New York State Podiatric Medical Associationcontracted with Navigant Consulting to quantify thevalue of podiatric services in helping reach New York healthcaregoals.2 Results of this analysis demonstrate a decrease in hospital-izations and lower healthcare costs for obese people who saw apodiatrist, compared to those who did not receive podiatric inter-vention.

The analysis revealed a 19% reduction in the odds of a subse-quent inpatient admission among obese persons receiving servicesprovided by a podiatrist, and a possible savings opportunity as highas $1.1 billion in healthcare costs through reduced hospitalizationsand other costs of care.

The results showed that inclusion of comprehensive podiatricse

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LERLER encourages a collaborative multidisciplinary clinical approach with an emphasis on functional outcomes and evidence-based medicine. LER is published monthly, except for a combined